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The diagnostic laboratory is essential to patient care and to the achievement of health equity. Through the development of quality laboratories in settings burdened by poverty and weak health systems, Partners In Health has demonstrated the critical contributions of clinical laboratories to the care of patients with HIV, tuberculosis, and cancer, among other conditions. The lessons learned through the organization's experience include the importance of well-trained and well-supported staff; reliable access to supplies, reagents, and diagnostic equipment; adequate facilities to provide diagnostic services; the integration of laboratories into networks of care; and accompaniment of the public health sector.

Liberia, a country recently afflicted by civil conflict and an epidemic of Ebola virus disease, has one of the highest rates of maternal mortality in the world. A biosocial analysis of this problem can help identify and address barriers impeding access to, and equitable delivery of, quality maternal health care. We analyzed 258 maternal death reviews reported to the National Public Health Institute of Liberia in 2017 and compared data with existing demographic and health statistics. Quantitative information on maternal death was contextualized with 44 in-depth interviews conducted among four groups of study participants. Forty percent of reported maternal deaths in 2017 occurred among women 25–34 years old; 36% were due to hemorrhage; 74% occurred at a health facility; and 29% occurred within 24 h after delivery. The number of deaths reported to the government of Liberia through maternal death reviews (n = 258) was substantially lower than the number expected based on the size of the population, crude birth rate, and the maternal mortality ratio. Qualitative findings highlighted inaccessible and unreliable transportation to health facilities; staff-related challenges, including staff attrition and burnout, inadequate training and clinical proficiency, staff absences, and neglect of patients; a lack of drugs and medical supplies; and the emergence of an inefficient and financially burdensome system of referrals by trained traditional midwives. Most notable was the finding that user fees for maternal health care in Liberia—eliminated in public facilities after the war—have resurfaced in the form of informal, out-of-pocket expenditures made by patients and their families. Keywords: Maternal mortality, User fees, Liberia, Structural determinants, Health equity

The diagnostic laboratory is essential to patient care and to the achievement of health equity. Through the development of quality laboratories in settings burdened by poverty and weak health systems, Partners In Health has demonstrated the critical contributions of clinical laboratories to the care of patients with HIV, tuberculosis, and cancer, among other conditions. The lessons learned through the organization's experience include the importance of well-trained and well-supported staff; reliable access to supplies, reagents, and diagnostic equipment; adequate facilities to provide diagnostic services; the integration of laboratories into networks of care; and accompaniment of the public health sector.

Despite over 28,000 reported cases of Ebola virus disease (EVD) in the 2013-16 outbreak in West Africa, we are only beginning to trace the complex biosocial processes that have promoted its spread. Important questions remain, including the effects on survivors of clinical sequelae, loss of family and livelihood, and other psychological and social trauma. Another poorly understood question is what effect social protection and job creation programs have had on survivors' wellbeing. Several clinical and social protection programs have been developed to respond to the needs of EVD survivors; however, little in the way of impact evaluation has taken place. We enrolled 200 randomly selected EVD survivors from Port Loko, Kenema, and Kailahun districts in Sierra Leone and stratified them based on the amount of instrumental social protection received post-discharge from an Ebola Treatment Unit. We then conducted a survey and in-depth interviews to assess participants' wellbeing and food security. Social protection categories II-IV (moderate to extensive) were each significantly associated with ∼15-22% higher wellbeing scores compared to minimal social protection (p 0.001). Only social protection category IV (extensive) was significantly associated with being food secure (adjusted odds ratio 6.11; 95% confidence interval, 2.85-13.10) when compared to minimal social protection. Qualitative themes included having a sense of purpose during the crisis (work and fellowship helped survivors cope); using cash transfers to invest in business; the value of literacy and life-skills classes; loss of breadwinners (survivors with jobs were able to take over that role); and combating the consequences of stigma. We conclude that, for EVD survivors, short-term social protection during the vulnerable period post-discharge can pay dividends two years later. Based on the empiric evidence presented, we discuss how terms such as "outbreak" and "epidemic" do symbolic violence by creating the illusion that social suffering ends when transmission of a pathogen ceases.

The advent of antiretroviral therapy (ART) in 1996 brought with it an urgent need to develop models of health care delivery that could enable its effective and equitable delivery, especially to patients living in poverty. Community-based care, which stretches from patient homes and communities—where chronic infectious diseases are often best managed—to modern health centers and hospitals, offers such a model, providing access to proximate HIV care and minimizing structural barriers to retention. We first review the recent literature on community-based ART programs in low- and low-to-middle-income country settings and document two key principles that guide effective programs: decentralization of ART services and long-term retention of patients in care. We then discuss the evolution of the community-based programs of Partners In Health (PIH), a nongovernmental organization committed to providing a preferential option for the poor in health care, in Haiti and several countries in sub-Saharan Africa, Latin America, Russia and Kazakhstan. As one of the first organizations to treat patients with HIV in low-income settings and a pioneer of the community-based approach to ART delivery, PIH has achieved both decentralization and excellent retention through the application of an accompaniment model that engages community health workers in the delivery of medicines, the provision of social support and education, and the linkage between communities and clinics. We conclude by showing how PIH has leveraged its HIV care delivery platforms to simultaneously strengthen health systems and address the broader burden of disease in the places in which it works.

Background Protective immunity against cholera is serogroup specific. Serogroup specificity in Vibrio cholerae is determined by the O-specific polysaccharide (OSP) of lipopolysaccharide (LPS). Generally, polysaccharides are poorly immunogenic, especially in young children. Methodology Here we report the evaluation in mice of a conjugate vaccine for cholera (OSP:TThc) made from V. cholerae O1 Ogawa O-Specific Polysaccharide–core (OSP) and recombinant tetanus toxoid heavy chain fragment (TThc). We immunized mice intramuscularly on days 0, 21, and 42 with OSP:TThc or OSP only, with or without dmLT, a non-toxigenic immunoadjuvant derived from heat labile toxin of Escherichia coli. Principal Findings We detected significant serum IgG antibody responses targeting OSP following a single immunization in mice receiving OSP:TThc with or without adjuvant. Anti-LPS IgG responses were detected following a second immunization in these cohorts. No anti-OSP or anti-LPS IgG responses were detected at any time in animals receiving un-conjugated OSP with or without immunoadjuvant, and in animals receiving immunoadjuvant alone. Responses were highest following immunization with adjuvant. Serum anti-OSP IgM responses were detected in mice receiving OSP:TThc with or without immunoadjuvant, and in mice receiving unconjugated OSP. Serum anti-LPS IgM and vibriocidal responses were detected in all vaccine cohorts except in mice receiving immunoadjuvant alone. No significant IgA anti-OSP or anti-LPS responses developed in any group. Administration of OSP:TThc and adjuvant also induced memory B cell responses targeting OSP and resulted in 95% protective efficacy in a mouse lethality cholera challenge model. Conclusion We describe a protectively immunogenic cholera conjugate in mice. Development of a cholera conjugate vaccine could assist in inducing long-term protective immunity, especially in young children who respond poorly to polysaccharide antigens., Author Summary Cholera is a severe dehydrating diarrheal illness of humans caused by organisms Vibrio cholerae serogroups O1 or O139 serogroup organisms. Protective immunity against cholera is serogroup specific. Serogroup specificity in V. cholerae is determined by the O-specific polysaccharide (OSP) of lipopolysaccharide (LPS). Generally, polysaccharides are poorly immunogenic, especially in young children. Unfortunately, children bear a large burden of cholera globally. Here we describe a novel cholera conjugate vaccine and show that it induces immune responses in mice, including memory responses, to OSP, the T cell-independent antigen that probably is the target of protective immunity to cholera. These responses were highest following immunization of the vaccine with a novel immunoadjuvant, dmLT. We also show that immunization of mice with this conjugate vaccine protects against challenge with wild-type V. cholerae. A protectively immunogenic cholera conjugate vaccine that induces long-term memory responses could have particular utility in young children who are most at risk of cholera.

BackgroundIn Liberia, an estimated 32% of children under 5 are stunted. Malnutrition and hunger worsened during the country’s civil war and were further exacerbated by the 2014–2016 outbreak of Ebola virus disease. Studies examining adherence to recommended infant and young child feeding practices frequently do so with an emphasis on the knowledge, attitudes and beliefs of mothers and caregivers. Often overlooked are the structural factors that enable or constrain their agency to practise evidence-based recommendations.MethodsBetween July and December 2017, we surveyed 100 Liberian mothers to assess the sociodemographic factors associated with the risk of severe acute malnutrition in children in Maryland County, Liberia. We also conducted 50 in-depth interviews at two government health facilities to qualitatively explore mothers’ experiences, as well as health workers’ understandings of the determinants of malnutrition in the region. We applied logistic regression to analyse quantitative data and inductive content analysis to thematically interpret qualitative data.ResultsMothers were less likely to have a child with severe acute malnutrition if they had an income greater than US$50 per month (adjusted OR (aOR)=0.14, pDiscussionThe lived experiences of Liberian mothers and health workers illustrate that child malnutrition is a direct consequence of abject poverty, food insecurity, illiteracy, the precarious nature of formal and informal work, and the lack of robust social protection. Behaviour change and health education interventions that do not seek to alleviate structural barriers to compliance are unlikely to be effective.